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SAN JOAQUIN COUNTY ENVIRONMENTALHEAI.,TH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE 111111T'l <br /> a <br /> OWNER/OPERATOR <br /> Thomas Beard c/o Siegfried Engineering CHECK If BILLING ADDRESS® <br /> FACILITY NAME <br /> SITEADDRESS 800N. Shaw Road Stockton 95215 <br /> Stra.i Numbor D rectlan Sirnnt Namo rity ZIr Codo <br /> HOME or MAILING ADDRESS (If Different from Site Address) 4045 Coronado <br /> Stroat Numb.! boot Nam. <br /> CITY Stockton STAT LA <br /> zip 95204 <br /> PHONE#1 EXT_ APN# LAND USE APPLICATION# <br /> 1 209)948-4803 143-270-38 / (2/0 <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> :A <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Tina Cheney <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT' <br /> Neil O. Anderson & Associates Inc. 209 367-3701 <br /> HOME or MAILING ADDRESS FAX# <br /> 902 Industrial Way 1209 )369-4228 <br /> CITY Lodi STATE CA ZIP 95240 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Grdinance Codes,Standards,STATE an FEDERAL laws. <br /> APPLICANT'S SIGNATURE:�_ .__� - / DATE:, <br /> PROPERTY/BUSINESS OWNER ` OPERATOR/MANAGER 13 OTHER AUTHORIZED AGENT❑ <br /> If APPLIGINT is 1101 the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: S��C7e—F14L+E ey'"u% 1 ifs ^� <br /> COMMENTS: l®�Gg 15-10 7 � ryw�• t c-zs�l: RECEIVED <br /> APR U 5 2001 <br /> SAN JOA <br /> ENVI OUIN COUNTY <br /> APPROVED BY: EPLOYEE#: UlE* �Irf <br /> ASSIGNED TO: S C , EMPLOYEE#: ���1' t{ DATE: S/ (j'� <br /> Date Service Completed (if already completed): $ERNCE CODE: 5 1 S P!E: � tJs <br /> Fee Amount: <br /> Amount Paid Payment Date <br /> Invoice#PaymentType O <br /> Check# Received Sy: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />